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Professor Mark Ashworth: Community care through General Practice

Professor Mark Ashworth

07 February 2024

Health

Professor Mark Ashworth's research and career has been led by a combination of clinical care and primary care research. Working for 30 years as a GP in Lambeth, Mark's experience in the local community has led him to focus on academic primary care. Below, Mark speaks about his career, the importance of community and how primary care data and trust can work towards tackling health inequalities.

I started as a GP back in 1986 working at a GP practice based on the ground floor of a 19-storey Lambeth Council owned tower block, close to Elephant & Castle. I worked in the same practice for 30 years, and had the huge privilege of becoming embedded within the life of the local community. It was my belief that all communities, particularly those in the most deprived areas of south London, should have access to excellence in terms of clinical care.

By the time I left clinical practice in 2016, the practice had grown and we had a large multi-professional team delivering primary care. Our practice had developed a special interest in mental healthcare and in managing substance dependency, both really challenging aspects of the role of the traditional GP (which I wasn’t!)

When I think about what made me want to be a GP the first thing that comes to my mind is about seeing the person, not just the medical condition. Although that is something of a cliché, as these days my hospital colleagues are also very good at seeing the person as an individual too. It’s also about continuity of care, you get to know individual patients over long periods of time, and their families. This relationship can also lead to you knowing their health beliefs, their health literacy, their worries and most importantly continuity of care – a unique feature of general practice.

It’s also about continuity of care, you get to know individual patients over long periods of time, and their families. This relationship can also lead to you knowing their health beliefs, their health literacy, their worries and most importantly continuity of care – a unique feature of general practice.– Professor Mark Ashworth

Another feature that drew me to general practice was the more holistic health agenda, of medical, psychological and social care. So often, the reason for the back pain or the headaches isn’t because of a ‘medical’ cause but is rooted in the mental health issues of the patient or their social issues associated with work, unemployment, housing or the cost of living crisis. Needless to say, we have strong links with our social work and benefits advisor colleagues.

Working in this role and being part of an inner-city community makes me think of one of the most important aspects of providing excellence in general practice. You can know all the very latest NICE guidelines for the management of Hypertension, or other Long-Term Conditions, but unless you have the trust of your community and your patients, it’s highly likely that you wont be able to implement ‘best practice’. Only by understanding the ideas and concerns of patients can you hope to provide great ‘hypertension care’ to all those patients registered at the GP practice, including those who normally wouldn’t come for GP appointments.

It was a real privilege working within an inner-city community, very rapidly learning how a deprived community’s healthcare needs were much greater than the needs in more prosperous communities, so the issue of ‘health inequalities’ was uppermost in my mind. The only problem was that without data, health inequalities are invisible. I could see in my everyday practice the huge unmet health needs of patients living in deprived communities, but I had no data to prove these increased needs.

It was a real privilege working within an inner-city community, very rapidly learning how a deprived communities healthcare needs were much greater than the needs in more prosperous communities, so the issue of ‘health inequalities’ was uppermost in my mind. The only problem was that without data, health inequalities are invisible.– Professor Mark Ashworth

This was how Lambeth DataNet began – as a way of collecting anonymous primary care data, linked to deprivation and ethnicity data, which could shine a light on health inequalities. The insights that Lambeth DataNet can provide goes beyond what the Office for National Statistics (ONS) breakdown and can highlight unique health needs of specific communities that are ‘hidden’ on the national census. For a multicultural community like South London it can also show differences between whether people are first generation migrants or were born in Britain – records ethnicity, language preference and country of origin.

To date a lot of my research involves working on the anonymous data from Lambeth DataNet. This database has been going since 2005. Over a period of almost 20 years, we now have data from 1.6 million patients of whom 420,000 are currently registered with GP practices in Lambeth. This is an excellent resource for my own healthcare research. I look at inequalities related to social deprivation, to ethnicity and to age. So many of these inequalities increase healthcare utilisation, placing considerable demands on primary care services.

I also look at how mental health conditions compound the demands on primary care as patients with these conditions often require input from the whole multidisciplinary primary care team together with support from community mental health services and talking therapy services. It’s not easy for patients when they have an accumulation of Long Term Conditions (so-called ‘multimorbidity’) when these conditions include a mix of physical and mental health conditions. It’s also not easy for general practice to provide the holistic care that is needed by these patients with complex combinations of Long Term Conditions

Lambeth DataNet in-action: Identifying the prevalence of chronic pain in a young, multi-ethnic, deprived community

Chronic pain is under-recognised in primary care and often patients are simply given analgesics, and if simple analgesics don’t work, then stronger more addictive analgesics like opioids. However, NICE guidance now recommends alternatives to medication for chronic pain, such as talking therapy, exercise, ‘holistic care’.

We decided to use Lambeth DataNet to identify the prevalence of chronic pain in a young, multi-ethnic, deprived community. What was new was that we devised a different way to identify patients with chronic pain. Other researchers had identified these patients based on regular prescriptions of analgesics. We also added in ‘diagnostic codes’ identifying patients with known chronic painful conditions such as osteoarthritis or endometriosis (our King’s College London research team also worked with Outcomes Based Healthcare to identify a list of conditions associated with chronic pain). As a result, we found that chronic pain was a lot more common than other researchers had previously demonstrated: based on Lambeth DataNet analysis, the overall prevalence of chronic pain in the adult population was 17%; it was 27% in the Black ethnicity community but 54% in Black Caribbean women. This startling finding was picked up for a special feature by BBC London: BBC (May 2023) and the Evening Standard: London Evening Standard (March 2023)

These findings were presented to NHS Lambeth Together (formerly ‘Lambeth CCG’) where the inequalities team responded by piloting an intervention project for ‘chronic pain’, particularly focussing on black women, focussed on Stockwell. With the evidence we provided, the PEACS project (Pain: Equality of Care and Support in the community) was set up in Stockwell. The Equalities lead for Lambeth, Dr Di Aitken was instrumental in setting up the project which offered ‘holistic healthcare assessments’ and appointments with the ‘social prescribing lead’. Early evaluation led by the IoPPN (Institute of Psychiatry, Psychology and Neuroscience) has shown promising results with reduced pain and reduced GP consultations for these patients.

This imaginative community based scheme appears to be heading for a great success in terms of addressing chronic pain issues in the Black ethnicity community of Stockwell. This problem was largely invisible until we were able to conduct the data analysis showing the scale of the problem, and how primary care needed to change the way it was addressing the healthcare needs of patients with chronic pain.